Inspection·February 10, 2023

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to maintain appropriate infection control practices while administering medications to 4 of 7 residents (R8, R15, R24, R89) reviewed for infection control in the sample of 30. Residents Affected - Some Findings include: On 2/7/23 from 4:25 PM to 5:01 PM, V13, Licensed Practical Nurse (LPN), was observed during PM medication administration pass. V13 failed to maintain appropriate infection control practices while administering medications to the following residents: 1. At 4:25 PM, V13 administered R8's PM medications including Atorvastatin 20 milligrams (mg), Buspirone 10 mg, Gabapentin 400 mg, Hydroxyzine 20 mg, Carafate 1 Gram (gm), Tylenol 650 mg, and Mylanta 15 milliliters (ml). V13 placed all the tablets into a small plastic pouch to crush them and poured the contents into a medication cup, and then opened R8's Gabapentin capsule with her bare hands and poured the contents of the capsule into the medication cup, added some applesauce and administered this to R8 with a spoon. 2. At 4:39 PM, V13 administered R24's PM medications including Cephalexin 500 mg and Depakote 125 mg. V13 opened both the Cephalexin capsule and Depakote capsule with her bare hands, poured the contents of each capsule into a medication cup, added some applesauce and administered this to R24 with a spoon. 3. At 4:47 PM, V13 administered R15's PM medications including Risperdal 0.5 mg, Buspirone 10 mg, Eliquis 5 mg, Iron 324 mg, Gabapentin 100 mg, Eye Caps Vitamin, and Tylenol 1000 mg. V13 placed all the tablets in a small plastic pouch and crushed them, and then poured the contents into a medication cup. V13 then opened R15's Gabapentin capsule with her bare hands and poured the contents into the medication cup, added applesauce and administered this to R15 with a spoon. 4. At 5:01 PM, V13 administered R89's PM medications including Eliquis 5 mg, Gabapentin 300 mg, and Tylenol 500 mg. V13 placed the tablets in a small plastic pouch and crushed them and poured the contents into a medication cup. V13 then opened the Gabapentin capsule with her bare hands and poured the contents into the medication cup, added applesauce and administered this to R89 with a spoon. On 2/9/23 at 9:56 AM, V2, Director of Nursing (DON), stated if a nurse must open a capsule to administer medications to a resident, that nurse should put on gloves before touching the medication. The facility's policy, Medication Administration, dated 1/11/10, documents, Objective: To provide accuracy during medication pass to assure quality care for residents. The policy does not address opening capsules during medication administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Staunton Health and Rehab Ctr 215 West Pennsylvania Avenue Staunton, IL 62088 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use for 4 of 5 residents (R32, R238, R240, R241) reviewed for antibiotic stewardship in the sample of 30. Residents Affected - Some Findings include: 1. The Facility's Infection Prevention & Control Monthly Log for October 2022 documents the Organism No Growth as cause for R32's urinary infection. The log documents R32 was treated with the antibiotic Macrobid. R32's Urine Culture collected at (Local Hospital) on 10/10/22 documents, Result: No Growth. R32's Progress Note written by V3, Infection Control Preventionist, on 10/17/22 at 6:47 PM documents, Final UA (urinalysis) results noted no growth, call to MD (medical doctor) asking if he would like to shorten duration. R32's Order Review Report printed 2/7/23 documents order for Macrobid Capsule 100 mg (milligrams) Give 100 mg by mouth two times a day for UTI (urinary tract infection) for 10 days with start date of 10/12/22 and end date of 10/18/22. R32's October 2022 Medication Administration Record (MAR) documents R32 received 13 doses of Macrobid. 2. The Facility's Infection Prevention & Control Monthly Log for November 2022 does not document an organism causing R238's urinary infection. R238's Urine Culture collected at (Local Hospital) on 11/17/22 documents, Result: No Growth. R238's Order Review Report printed 2/7/23 documents order for Cephalexin Capsule 500 mg - Give 500 mg by mouth every 8 hours for UTI for 7 days. R238's November 2022 MAR documents R238 received 21 doses of Cephalexin. 3. The Facility's Infection Prevention & Control Monthly Log for October 2022 documents the Organism <10,000 single gram neg (negative) organism as cause for R240's urinary infection. R240's Urine Culture collected at (Local Hospital) on 10/20/22 documents, Result: Less than 10,000 CFU/mL (colony forming units per milliliter) of single Gram-negative organism isolated. No further testing will be performed. If clinically indicated, recollection using a method to minimize contamination, with prompt transfer to Urine Culture Transport Tube, is recommended. R240's Order Review Report printed 2/7/23 documents order for Levofloxacin Tablet 250 mg - Give 250 mg by mouth every 48 hours for UTI for 5 administrations with start date 10/24/22 and end date of 10/24/22. There is a second order for Levofloxacin Tablet 250 mg - Give 250 mg by mouth every 48 hours for UTI for 5 administrations with start date of 10/26/22 and end date of 11/5/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 145286 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Staunton Health and Rehab Ctr 215 West Pennsylvania Avenue Staunton, IL 62088 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 R240's October and November 2022 MARs documents R240 received 6 doses of Levofloxacin. Level of Harm - Minimal harm or potential for actual harm 4. The Facility's Infection Prevention & Control Monthly Log for November 2022 does not document an organism as the cause for R241's UTI. Residents Affected - Some On 2/7/23 at 10:45 AM, a urine culture for R241's UTI in November 2022 was requested from V2, Director of Nursing (DON). R241's Progress Note written by V3, Infection Control Preventionist, on 11/29/22 at 1:49 PM documents, MD (medical doctor) notified. MD was notified of UA (urinalysis) done over in ED (Emergency Department) on 11/26/22. Abx (antibiotic) was ordered. Followed up with C&S (culture and sensitivity) and that was no (not) done in ED. MD notified of this situation and wanted to know if he would like to D/C (discontinue) Abx or if to continue due to elevated WBC (white blood cell) of 14. R241's Order Review Report printed 2/7/23 documents order for Sulfamethoxazole-Trimethoprim Tablet 800-160mg - Give 1 tablet by mouth every 12 hours for UTI per hospital for 20 administrations with start date of 11/27/22 and end date of 12/1/22. R241's November and December 2022 MARs documents R241 received 8 doses of Sulfamethoxazole-Trimethoprim Tablet. On 2/9/23 at 9:57 AM, no culture for R241's UTI was received by the Facility. V2, DON, stated, It is the company's expectation to get residents off inappropriate antibiotics. We try to notify the doctors and educate them, but we cannot write the orders. The Facility's Antibiotic Stewardship Protocol, undated, documents, The World Health Organization has reported that antibiotic resistance is one of the major threats to human health, especially because some bacteria have developed resistance to all known classes of antibiotics. According to the CDC (Centers for Disease Control), improving the use of antibiotics in healthcare to protect patients and reduce the threat of antibiotic resistance is a national priority. Diseases caused by these bacteria are increasing in long-term facilities and contributing to higher rates of morbidity and mortality. It is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. Leadership: A written statement of leadership support to improve antibiotic use is in place. (This support is also present at the corporate level as needed). The Medical Director will assist in communicating the facility's expectations for antibiotic use to prescribing clinicians as needed. The antibiotic stewardship review is a part of the Infection Prevention and Control Program in this facility and is overseen by the Infection Prevention and Control Committee. The Medical Director, Director of Nursing, Infection Preventionist and the consultant pharmacist are all considered leads for antibiotic stewardship activities. As a team they will: Review infections and monitor antibiotic usage patterns on a regular basis; Obtain and review antibiograms from admitting hospitals when available for trends of resistance. Facility optimizes the use of diagnostic testing following physician's orders. The Infection Preventionist will be responsible for infection surveillance and MDRO (multi-drug resistant organism) tracking. The Infection Preventionist will collect and review data such as: McGeer Criteria for positive signs of infection; Antibiotic used and route of administration; Whether appropriate tests such as cultures were obtained before ordering antibiotic; Whether the antibiotic was correct based on the sensitivity report; Whether the antibiotic was changed during the course of treatment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 145286 If continuation sheet Page 4 of 4